Familiarize yourself with the major health plan accreditors
The healthcare industry has long used credentialing processes, especially in the hospital setting, which must follow the requirements of the Centers for Medicare & Medicaid Services (CMS), The Joint Commission, and other organizations that accredit healthcare entities. In the health insurance environment, NCQA and URAC are the main accrediting bodies.
Accreditation or certification for managed care credentialing is designed to establish a minimum standard that health plans can use to identify individuals and facilities that are appropriately qualified to participate in their networks and provide quality care to their members. The following is a high-level overview of the two accreditors recognized within the health insurance industry.
National Committee for Quality Assurance (NCQA)
NCQA, founded in 1990, has established credentialing standards that are applicable to health plans, managed behavioral healthcare organizations, credentials verification organizations, and physician organizations. NCQA’s CVO certification program evaluates credentials verification operations and processes to continuously improve the services it provides to its managed care clients.
The NCQA CVO Certification Survey comprises onsite and offsite evaluations conducted by a survey team that includes at least one Credentialing and Recredentialing surveyor and one administrative surveyor. A Review Oversight Committee (ROC) of physicians analyzes the survey team’s findings and assigns a certification status based on the CVO’s performance against core standards and the requirements within applicable certification options.
URAC (formerly known as the Utilization Review Accreditation Commission), was formally incorporated in 1990 and offers more than 30 accreditation and certification programs. URAC accredits healthcare organizations based on functions. Its accreditation programs provide a range of services, from organizational review of health plan standards to boosting quality within a single functional area, such as case management or credentialing.
Organizations performing the functions covered by a URAC accreditation may apply, including hospitals, health maintenance organizations, preferred provider organizations, third-party administrators, and provider groups. Accreditation includes a four-stage process: application, desktop review, on-site review, and committee review.
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